Failure to Assess and Document Use of Bed Rails and Bed Placement as Restraints
Penalty
Summary
The facility failed to ensure that bed placement and the use of bed side rails were properly assessed, physician ordered, and accompanied by informed consent for three residents who were reviewed for physical restraints. Specifically, for one resident with moderate cognitive impairment, a quarter rail was observed on the bed during multiple observations, but there was no evaluation assessment, consent, or physician's order documented in the electronic health record. For another resident with hemiplegia and hemiparesis following a stroke, the bed was consistently observed with one side against the wall, yet there was no related assessment, consent, or physician's order. A third resident, also moderately cognitively impaired, was found with the bed against the wall and was unaware of the reason; again, no evaluation, consent, or physician's order was found in the record. Staff interviews confirmed that the expected process was not followed, as both the Resident Care Manager (LPN) and the Chief Nursing Officer (RN) acknowledged that evaluation assessments, consents, physician orders, and care plans should have been in place for the use of bed rails or beds placed against the wall. The facility's own policy requires these steps for the use of restraints and bedrails, including assessment, care planning, physician order, and informed consent, none of which were documented for the affected residents.